1. Dead or Alive: Managing Both in Mass Fatality Incidents Martin A. Luna, D-ABMDI Laramie County Coroner Cheyenne, Wyoming

2. Poll Question In my career, the largest mass fatality incident that I have worked on involved A.6–20 fatalities B.20–100 fatalities C.Over 100 fatalities D.I have never worked on a mass fatality

3. Definition What is mass fatality?  Number of victims  Capacity of affected jurisdiction to respond  The type of disaster

4. Natural disasters Accidents/ incidents Pandemic events Onset Sudden Unexpected Sudden Unexpected Expected Preplanning Deaths Hundreds or thousands Tens or hundreds Hundreds or thousands Infectious disease issues Same Potentially very high Legal context “Nobody responsible” Medicolegal framework Public health legal issues Forensic investigation Identification Cause of death Identification Cause of death Actual cause of death A Descriptive Framework

5. Commonalities All victims must be identified The need to preserve evidence Treat remains and relatives with dignity and respect Political pressure Public health concerns

6. Public Health Why take a public health approach to management of the dead following mass fatalities incident?  Not just about identification  Physical health of survivors and relief workers  Impact on other healthcare providers  Mental health  Legal issues  Assessing the impact of the disaster

7. Assessing Disease Risk Presence of infectious agent Exposure to the agent Susceptible host Victims of natural disasters die from trauma/drowning/fire Unlikely to have acute (epidemic) infections Possible chronic infections Natural disasters Public usually not exposed Body handlers most likely to be exposed Susceptible to common chronic infections TB HBV & HCV HIV/AIDS Enteric pathogens O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

8. Assessing Disease Risk Presence of infectious agent Exposure to the agent Susceptible host Victims of natural disasters die from trauma/drowning/fire Unlikely to have acute (epidemic) infections Possible chronic infections Natural disasters Public usually not exposed Body handlers most likely to be exposed Susceptible to common chronic infections TB HBV & HCV HIV/AIDS Enteric pathogens Gloves Basic hygiene Vaccination TB, HBV O Morgan. Rev Panam Salud Publica. 2004: 15(5);307-12

9. Risk to the Public Assessment suggests low risk Public may be isolated from incident Mortuary personnel may be the only “general public” at risk of exposure

10. Workers Potentially a “high risk group” No “occupational” infections Physical injuries Hazardous working environment  Injury  Tetanus  Hepatitis

11. Body Recovery Feel the need to begin immediately Confusion Lack of prepared recovery personnel Those that die in medical care facilities

12. Equipment: Basic Local equipment usually available

13. Equipment: Technical More sophisticated equipment  Not available  Necessary?  Time to respond

14. Managing Body Recovery Difficult to set up systems for body recovery “after” the disaster Should be considered as part of preparedness at local level Expectation that it will begin soon after the incident

15. Challenges Public/media want rapid disposal of bodies Demand proper identification of victims Short time before decomposition Identifying suitable storage Limited resources Preserve as much evidence as possible Families wanting closure now!

16. Methods for Identification Viewing and visual identification Individual identifying features (scars, marks, tattoos) Collection of photographs Advance forensic techniques  Fingerprints  Dental  DNA Other

17. Viewing Decomposition may be too advanced after 24–48 hours Logistically very difficult to arrange Distressing for relatives Error potentially quite high

18. Photographs Photographs: face and body As soon after as possible Possibly the best postmortem information available in mass fatality incident Not as simple to do as it sounds  Quality of photographs  Availability of photographic equipment  Cost

19. Advanced Forensic Methods Standard methods  Lack of antemortum data  Availability of resources DNA techniques  Collection of sample material  Facilities and expertise unavailable  Cost and practicability

20. Other Methods Personal effects  Identity cards  Distinctive jewellery  Clothing Location of body Posters and flyers of missing Internet sites

21. Suggestions for Identification Photographs and documentation Personal effects data Viewing and visual identification if possible + Storage + Forensic investigation when needed

22. Data Management What do we do with the data?  Lots of photos, information.  Difficult to use for identification.  Who owns the data?  Who verifies the identification process?  Provided for “lessons learned.”  Legal aspects.

23. Poll Question In your jurisdiction, how many bodies can be stored at once? A.1-10 B.10-20 C.More than 20 D.I don’t know

24. Storage Not possible to keep bodies for long without storage Limited options if numerous bodies  Refrigeration  Ice  Dry ice  Temporary burial

25. Refrigeration Existing facilities too small Funeral homes do not have capacity to hold too long Refrigerated trucks can be used Up to 45-50 bodies in each container

26. Burial Preserve evidence Location of suitable grave sites difficult  Local communities  Environmental health concerns Operational difficulties  Lack of suitable documentation  Single graves or trench graves?  Clearly marked, not a “hole in the ground”  Minimum burial depth, distance from water sources, etc.

27. Coordination and Support Body Recovery Communities, volunteers, police, military, non-governmental organizations (NGOs) Identification Doctors, medical staff, forensic specialists, FBI, DMORT, NGOs Death certification Coroners, physicians Disposal Coroner, ME, funeral directors

28. Technical Support Planning assistance for technical support Potential sources of support  American Red Cross  Mutual aid  DMORT

29. Disaster Preparedness Develop fatalities management plans Build local capabilities  Police/Fire  Military  Red Cross  Hospitals  Mental health organizations  Clergy  State partners  Public health

30. Review 1.Consider whether recommendations are suitable to all “mass fatality events.” 2.Time for action is short.  Decomposition 24–72 hours  Body recovery begins immediately 3.Specialized equipment or teams may arrive too late. 4.Simple methods of identification and data management need to be developed 5.Temporary burial may be best storage option where refrigeration is unavailable

31. 6.Management of dead needs to be included in disaster preparedness. 7.Coordination by single person/agency with clear mandate and legal authority. 8.Technical support is needed for governments/local organizations. 9.Active engagement with the media. 10.Ongoing program of systematic learning from future natural disasters. Review (cont.)

32. Above All… Planning Training Exercising  Exercise beyond “The Hero”  Include multi-disciplinary approach to exercises After Action Reports—Implement

33. And More… Yearly training in fatalities management issues Additional time spent exercising recovery and processing Develop capabilities now

34. Sources A Working Group Consensus Statement on Mass Fatality Planning for Pandemics and Disasters: July 2007  Joint Task Force Civil Support Mass Fatality Working Group www.homelandsecurity.org/newjournal/Articles/displayArticle2.asp? article=160

35. Questions Martin A. Luna, D-ABMDI Laramie County Coroner 310 West 19 th Street, #410 Cheyenne, WY 82001 307.633.4513 mluna@laramiecounty.com